Resuscitation of pulmonary hypertension and right ventricular failure

A guide to the initial emergency department management of patients with pulmonary hypertension and right ventricular failure

Case

A 40 year old female presents by EMS with significant dyspnea. She has had a fever and cough for 2 days, and has been getting progressively more short of breath. Today, she almost fainted when she stood up, so she called 911. Her vital signs are HR 135, BP 88/45, RR 35, and an oxygen saturation of 90% on a nonrebreather. She is quite somnolent. As she is being transferred to the stretcher, the paramedic mentions that she has a pump of some sort to treat her pulmonary hypertension…

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Guidelines on intubation in critically ill patients

Some key take home points from a new guidelines on airway management in critically ill patients

Just as I set the last blog post in the airway series to post, a fantastic guideline was published on intubation in critically ill adult patients. It covers most of the content I tried to cover in those posts, and probably does a much better job. I recommend that everyone take the time to read it. I have already covered a lot of this information in the airway series, but as a way of reinforcing the lessons from those posts, I thought I would go through my personal takeaways from this document.

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Emergency Airway Management Part 5: Post intubation care

A guide to managing patients in the immediate post-intubation period

Case

A 55-year-old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him, prior to proceeding with intubation. You pass the tube easily on the first attempt. Looking around the room for someone to high-five, you realize your team is waiting for your instructions for the ongoing care of this sick patient…

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Emergency Airway Management Part 4: Cricothyroidotomy (surgical front of neck access)

An approach to managing the emergency department patient in a can’t intubate can’t oxygenate scenario

Case

A 55 year old man was found unconscious in the bathroom by his family. After appropriate resuscitation and pre-oxygenation, you determine that there are no major predictors of difficulty, and so proceed with RSI. On 2 attempts at laryngoscopy, both direct and video, you cannot visualize the cords. The LMA won’t sit properly, and now his oxygen saturation is 70% despite your best attempt at bag valve mask ventilation…

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Emergency Airway Management Part 3: Intubation – the procedure

An approach to intubation in the emergency department

Case

A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. After using basic airway maneuvers to temporarily stabilize his airway, you were able to take the time to appropriately resuscitate and pre-oxygenate him. His vital signs are now a heart rate of 105, a blood pressure of 122/77, a respiratory rate of 16, and an oxygen saturation of 100% with a non-rebreather set at flush rate and nasal prongs at 15 L/min. However, he remains unconscious and you think it is now time to proceed with intubation…

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Emergency Airway Management Part 2: Is the patient ready for intubation?

An approach to managing important pre-intubation physiology

Case

A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs on arrival are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. Although he was originally making sonorous noises, after elevating the head of the bed to 30 degrees, inserting a nasopharyngeal airway, and applying a jaw thrust, he is breathing quietly at 23 breaths a minutes, and his oxygen saturation has climbed to 92% with facemask oxygen…

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Emergency Airway Management Part 1: Optimizing the basics

An approach to the initial airway management of emergency department patients

Case

A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. He is lying flat on the resuscitation stretcher and making some sonorous breath sounds. You resident grabs a laryngoscope and says, “ABCs… let’s get this guy intubated”…

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